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A nurse is observing a newly licensed nurse set up a sterile field. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure?
- A. Prepares the sterile field 2 hr before it is needed
- B. Uses a surface that is at waist height
- C. Places the sterile field against a wall in the client's room
- D. Opens the first flap of the sterile package towards the nurse's body
Correct Answer: B
Rationale: The correct answer is B because setting up a sterile field at waist height minimizes the risk of contamination. This position ensures better visibility and accessibility for the nurse while maintaining sterility. Choice A is incorrect as preparing the sterile field too early can lead to contamination. Choice C is incorrect as placing the sterile field against a wall increases the risk of contamination from the wall. Choice D is incorrect because the first flap should be opened away from the body to prevent contamination.
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A nurse is teaching a class about reducing the risk of medication errors. Which of the following information should the nurse include?
- A. Provide a dedicated area for the nurse to prepare medications
- B. Wait to document medications given to clients until the end of a shift
- C. Remove medications from automatic dispensing systems before they are reviewed by pharmacists
- D. Prepare medications for multiple clients at the same time
Correct Answer: A
Rationale: Correct Answer: A - Provide a dedicated area for the nurse to prepare medications.
Rationale: Providing a dedicated area for medication preparation helps reduce distractions and promotes focus, decreasing the likelihood of errors. This setup allows for organization and prevents cross-contamination. It also encourages proper storage and disposal of medications, fostering a safer environment for medication preparation.
Summary of Other Choices:
B: Waiting to document medications until the end of a shift can lead to errors in documentation and potential confusion. Real-time documentation is crucial for accuracy.
C: Removing medications from automatic dispensing systems before pharmacist review bypasses a critical safety check, increasing the risk of errors.
D: Preparing medications for multiple clients simultaneously can lead to mix-ups and errors, as it increases the chances of confusion and incorrect dosing.
A nurse is assessing a client who has fluid overload. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Increased blood pressure
- B. Increased hematocrit
- C. Increased respiratory rate
- D. Increased heart rate
- E. Increased temperature
Correct Answer: A,C,D
Rationale: The correct answer is A, C, and D. Fluid overload leads to increased blood pressure due to the increased volume of fluid in the vascular system. Increased respiratory rate occurs as the body tries to compensate for the excess fluid by increasing oxygen intake. Increased heart rate is a response to the increased workload on the heart to pump the excess fluid. Increased hematocrit and temperature are not typically associated with fluid overload. Hematocrit may actually be decreased due to hemodilution, and temperature is usually unaffected unless there is an underlying infection.
A nurse is reviewing a fall risk assessment for a client. Which of the following findings places the client at risk for a fall? Select all that apply.
- A. Electrical cord on floor over a walkway
- B. Demonstrates correct use of cane to ambulate
- C. Grab bar in the bathroom
- D. Diagnosis of macular degeneration
- E. Throw rugs in kitchen
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- A: An electrical cord on the floor is a tripping hazard, increasing the risk of falls.
- D: Macular degeneration affects vision, leading to difficulties in depth perception and obstacle detection, increasing fall risk.
- E: Throw rugs in the kitchen can cause slipping or tripping, posing a fall hazard.
Summary of Incorrect Choices:
- B: Demonstrating correct use of a cane indicates the client is taking precautions to prevent falls.
- C: Having a grab bar in the bathroom is a safety measure to prevent falls.
- F and G: Not provided in the question, so cannot be evaluated.
A nurse is receiving a telephone prescription for a client from a provider. Which of the following actions should the nurse take when transcribing the prescription?
- A. Use the provider’s initials after the prescription
- B. Repeat the prescription to the provider
- C. Write the prescription in shorthand
- D. Read back the prescription to the provider
Correct Answer: D
Rationale: The correct answer is D: Read back the prescription to the provider. This is crucial to ensure accuracy and prevent errors. By reading back the prescription, the nurse confirms understanding and allows the provider to clarify any misunderstandings immediately. This step promotes patient safety and effective communication.
Choice A (Use the provider’s initials after the prescription) is incorrect because it does not address the need for verification of the prescription details. Choice B (Repeat the prescription to the provider) is not as effective as reading back, as it may not ensure complete accuracy. Choice C (Write the prescription in shorthand) can lead to misinterpretation and errors.
A nurse is preparing to administer clonazepam 5 mg PO in 3 equally divided doses every 8 hr for a client who has seizures. The amount available is clonazepam 0.5 mg tablets. How many tablets should the nurse administer per dose? (Round off to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 1
Rationale: Correct Answer: 1
Rationale: To calculate the number of tablets per dose, divide the total dose (5 mg) by the dose per tablet (0.5 mg).
5 mg / 0.5 mg = 10 tablets for the total dose.
Since the total dose is divided into 3 equal doses, divide the total tablets by 3.
10 tablets / 3 = 3.33 tablets per dose.
Round off to the nearest tenth, which is 3.3.
Since we cannot administer a partial tablet, the nurse should administer 1 tablet per dose.
Summary:
A: 1 - Correct. Calculated based on dividing total dose by dose per tablet and rounding off.
B: 2 - Incorrect. Not the correct calculation based on the dose per tablet.
C: 3 - Incorrect. Not the correct calculation based on the dose per tablet.
D: 4 - Incorrect. Not the correct calculation based on the dose per tablet.
E